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Friday, March 30, 2012

Studying for the American Board of Internal Medicine Maintenance of Certification Exam

In 1989 after finishing my residency in Internal Medicine at the University of Washington, I sat down and took the Internal Medicine Boards. I didn't study, didn't look at any information about the test at all ahead of time and passed in the top 10%. It made perfect sense that it would go that way: I had been eating, drinking and sleeping (sometimes) internal medicine for 3 solid years in an excellent program, studying all the time and practicing under recognized opinion leaders in the field. Prior to that I had eaten, drunk and slept the entire field of medicine for 4 years at Johns Hopkins School of Medicine where my mind was positively marinated in everything that was then thought to be true about physiology, pathophysiology and care of patients.

When I took the test it was the last time I would ever have to take it. I was forever certified with American Board of Internal Medicine, and the next year all of the doctors who passed the test would have to re-take it every 10 years to maintain certification. Lucky me, I thought. Under the wire.

For the last 20 years I have been educating myself by reading journals regularly, attending classes in medical things that interest me, taking online education, maintaining proficiency in things like Advanced Cardiac Life Support, teaching medical students and generally keeping updated on what I do. I have been documenting at least 50 hours a year of education, which is enough to maintain licensure in both of the states in which I practice. The number of hours varies by state, along with details of how the hours must be spent, and many require less than 50, but I figure if I get 50 I don't have to check the requirements and I'll be fine.

Last year after reading this article ( I decided to start the process of recertifying for the board of internal medicine. It just seemed like the right thing to do. It has been, so far, a very interesting ride. I take the test on April 25.

The board requires demonstrating proficiency in a number of areas via open book tests plus a module of practice improvement, in which I evaluated my present practice using chart reviews and patient questionnaires, made a change in what I did and then repeated the process. I chose to look at how I presented information about preventive testing. It caused me to deliver this information more comfortably and routinely and to write a handout that was based on current recommendations rather than relying on information that had been in my electronic medical record's handout collection that was inaccurate and outdated. The open book multiple choice tests were in many of the subject areas that comprise internal medicine and were meant to be equivalent to about 80 hours of study, though I did more random tests than that because it was interesting. It's after finishing all of this that the board allows me to sit for the test.

At the end of last year I attended Harvard Medical School's marathon update in internal medicine and found that my knowledge of this humongous field that I practice was no longer at the cutting edge. When presented with cases and questions and given multiple choice questions to answer with a little remote clicker I was no longer always right. Whoa. That was weird. It was clearly time to catch up. But how? First of all, being a hospitalist at a completely different place, seeing lots of patients along with specialists has been great. I can't necessarily trust that they are on the cutting edge, but I can see how their practice seems to work and I can read. In this last month leading up to the test I have begun to immerse myself in two sources that are absolutely wonderful tools for regaining mastery (hah!) of all of this stuff.

The first is the MKSAP, the medical knowledge self assessment program of the American College of Physicians. I took the MKSAP about 10 years ago as an educational tool and back then it was terrible. It was in print, very boring and often just plain wrong. MKSAP now is a different animal. It is still wrong at times, but because of reasonable difference of opinion, not carelessness. It is online and is updated and corrected constantly. I use the very long multiple choice tests as a framework for learning the materials, reading the question, deciding what my answer would be, then checking the syllabus materials with a focused question in mind. Then I go to my new favorite resource to check out what an entirely different set of physicians think about the subject. That resource is Up to Date ( Although it is expensive, a year's subscription is almost $500, when I use it, it monitors my time and documents that as continuing medical education credits. Plus it is absolutely excellent. It presents the data behind different approaches to a problem, recognizes variability in practice, and sometimes disagrees with the MKSAP. It does make me think. This studying is an exciting process and I'm really enjoying it. I know it will impact the way I treat patients in a positive way.

The expense of doing all of this is considerable. The maintenance of certification itself was $1675. The MKSAP was $574. Up to date was $499, but I will use it for other things. The Harvard Medical School course was $1675 plus about $2500 for airfare and hotel. The time I didn't work (in my old practice) would have cost about $5000 in missed revenue plus paying staff while I wasn't around, for just the Harvard course. Now that I am doing hospitalist shifts, the process of studying is roughly equivalent to missing a month's worth of shifts, maybe about $18,000 before taxes and expenses. It's a little like being in school again: expensive, time consuming and eminently worth it.


MKSAP said...

$18k, ouch! Thanks for sharing all of the details though. And good luck on the re-certification test this month!

Janice Boughton said...

I passed!

Anonymous said...

congrats!! how did the test compare with the first time around?
was it similar in format? all multiple choice. one full day exam?